Fibromyalgia

What is Fibromyalgia?

Fibromyalgia (FM) is a condition that causes long-term, widespread body pain. People with fibromyalgia often also struggle with constant tiredness, difficulty thinking or concentrating, emotional distress, and numerous other physical symptoms. The exact cause of fibromyalgia remains unclear, and there isn’t a fully understood explanation for how it develops. Despite soft tissue pain being a common symptom, there is no proof of actual inflammation in the body. Current research suggests that fibromyalgia is a disorder of pain regulation and it is often seen as part of a larger group of conditions known as central sensitization syndromes.

In simpler terms, fibromyalgia is a disorder related to the nerves, which alters how the brain processes pain.

What Causes Fibromyalgia?

Fibromyalgia is a long-term condition characterized by chronic pain, and we’re not exactly sure what causes it. Rather than being triggered by a single event, it can be sparked or worsened by a mixture of physical and emotional stresses. These can range from infections to both emotional and physical trauma.

This condition is thought to be related to how pain is regulated in the body. Some research suggests a genetic likelihood for fibromyalgia, although no specific gene has been pinpointed. People with fibromyalgia tend to experience pain and sensory changes in their nervous system. For example, they might start to feel pain at lower levels of physical pressure compared to healthy individuals.

Interestingly, when repeatedly exposed to brief uncomfortable stimuli, people with fibromyalgia often report a higher increase in their pain perception than normal. This suggests there might be an issue with the internal pain control systems in people with this condition. Brain imaging techniques have shown differences in the activity of pain-sensitive areas of the brain in fibromyalgia patients.

Risk Factors and Frequency for Fibromyalgia

Fibromyalgia affects more women than men, with 6.4% of people in the United States having this condition. Of these, 7.7% are women and 4.9% are men. In Europe and South America, the prevalence of fibromyalgia ranges from 3.3% to 8.3%. The chances of having fibromyalgia increase with age. From ages 20 to 55, the main cause of widespread muscle and joint pain in women is usually fibromyalgia. The number of adolescents with this condition is similar to that of adults. In pain clinics, more than 40% of patients could potentially have fibromyalgia. Those with an existing rheumatic disease have a higher risk of developing fibromyalgia.

• Fibromyalgia is more common in women, with a prevalence of 7.7%, compared to 4.9% in men, in the United States.
• The percentage of people with fibromyalgia in Europe and South America is between 3.3% and 8.3%.
• The likelihood of getting fibromyalgia increases as one ages.
• Between the ages of 20 and 55, generalized muscle and joint pain in most women is due to fibromyalgia.
• The proportion of adolescents with fibromyalgia is similar to that of adults.
• More than 40% of patients in pain clinics may have fibromyalgia.
• People with a rheumatic disease have a higher chance of getting fibromyalgia.

Signs and Symptoms of Fibromyalgia

Fibromyalgia is a condition that primarily results in widespread body pain and fatigue. In many cases, there also exist cognitive and psychiatric problems.

• The main symptom is widespread body pain that affects both sides and all sections of the body. The pain generally starts in localized regions like the neck and shoulders before spreading elsewhere. Patients typically describe it as muscle pain, but joint pain can also occur.
• Fatigue is a significant part of this condition, and patients experience it intensely upon waking up and during the mid-afternoon. Light activities or prolonged inactivity can make the pain and fatigue worse. Most patients wake up feeling stiff and often complain about a light, interrupted sleep that leaves them unrefreshed, even after 8 to 10 hours.
• The cognitive disturbances in fibromyalgia patients often lead to difficulties with attention spans, particularly when dealing with tasks that require rapid changes in thought. These disturbances are often referred to as “fibro fog”.
• Around 30 to 50 percent of patients show signs of anxiety or depression when diagnosed with fibromyalgia. Also, more than half of patients have headaches like migraines and tension types. Symptoms of numbness, especially in the arms and legs, are common, although neurological tests usually return normal results. Patients also have a higher propensity for gastrointestinal issues, dry eyes, shortness of breath, difficulty swallowing, and heart palpitations.

Earlier diagnostic criteria for fibromyalgia, established in 1990, included tenderness in at least 11 of 18 specific points across the body. These points ranged from various muscle insertions and junctions to certain sections of the buttocks, knees, and more, on both sides of the body. However, due to limitations, these criteria were abolished in 2010.

Testing for Fibromyalgia

Usually, regular clinical tests or medical imaging, like x-rays or MRIs, don’t reveal any abnormalities in people with fibromyalgia. However, in research studies, certain forms of specialized imaging, like functional MRI, have shown some differences between people with fibromyalgia and those without.

Fibromyalgia is diagnosed using certain criteria. In 1990, the American College of Rheumatology (ACR) put forth a classification criteria to diagnose fibromyalgia. It included extensive pain in the body which should be present on both sides and both above and below the waist. Additionally, clinicians looked for a minimum of 11 tender points (out of 18) in the body when certain pressure was applied. These tender points are specific locations on the body that are extremely sensitive to pressure in people with fibromyalgia.

Despite its use in several clinical and therapeutic trials, the 1990 ACR classification criteria haven’t been helpful for diagnosing fibromyalgia in daily medical practice. So, due to certain shortcomings, these criteria were modified, first in 2010 and then further refined in 2011 and 2016.

As part of the latest criteria, a patient is said to have fibromyalgia if they fulfill the following conditions:

1. The widespread pain index (WPI), which measures the number of areas where a patient has experienced pain in the past week, is 7 or more and their symptom severity (SS) score is 5 or more. Alternatively, a patient can qualify if their WPI is between 3 and 6 and their SS score is 9 or more.
2. They’ve been experiencing a similar level of symptoms for at least three months.
3. No other medical condition can explain their pain.

The SS scale is used to rate the severity of three symptoms: fatigue, waking up feeling tired, and cognitive issues. The scale rates these from 0 (no problem) to 3 (severe), with the final score ranging between 0 and 12. The scale also takes into account the number of somatic or physical symptoms one experiences.

Treatment Options for Fibromyalgia

• The approach to patients with fibromyalgia includes educating patients regarding the disease and treatment approaches, exercise regimen, and drug therapy for patients not responding to non-pharmacologic measures.

Patient Education

• Reassuring the patient that fibromyalgia is a real disease.
• There is a role of stress and mood disturbances, and patients with fibromyalgia should be encouraged to learn relaxation techniques as well as be a part of formal stress reduction programs. About 30% of patients with fibromyalgia have major depression at the time of diagnosis, and the lifetime prevalence is 74%. The lifetime prevalence of anxiety disorder is 60%. These patients should be encouraged to get treatment.
• Good sleep hygiene is an essential part of the management of fibromyalgia, and recognizing and obtaining treatment for sleep disorders that may contribute to symptoms of fibromyalgia is equally important.

Exercise

• Cardiovascular fitness training is recommended for patients as it helps with pain and improves sleep.

Medications

• It is recommended to continue nonpharmacologic measures along with the use of medications for most patients with fibromyalgia. Some patients may, however, respond adequately to nonpharmacologic measures alone. The medications that have been well-studied and consistently effective are certain antidepressants and anticonvulsants. The antidepressants include tricyclic medications, like amitriptyline and other selective serotonin reuptake inhibitors (SSRIs) and norepinephrine reuptake inhibitors (SNRIs), including duloxetine and milnacipran. Cyclobenzaprine, a tricyclic medication, has also been found to be effective in patients with fibromyalgia. The beneficial anticonvulsants include gabapentin and pregabalin. The three drugs for the treatment of fibromyalgia approved by the US Food and Drug Administration (FDA) are pregabalin, duloxetine, and milnacipran. Therapy most often initiates with tricyclic antidepressants. An SNRI or one of the anticonvulsants is an option in patients with inadequate response or intolerance to tricyclic antidepressants. However, in a patient with more severe fatigue, depression, or severe sleep disturbance, an SNRI or an anticonvulsant is recommended.

Treatment for persistent symptoms

• Despite the initial treatment with nonpharmacologic measures and single pharmacologic agents at maximum tolerated dose, many patients continue to be symptomatic. In those patients, the following are the current recommendations.
• It is recommended to use a combination drug therapy in patients not responsive to monotherapy.
• Encouraging participation in a supervised physical exercise program for patients who have difficulty reaching a sufficient level of low-impact aerobic exercise. Referral to a physiatrist and/or a physical therapist would be helpful for these patients. Water-based exercises and yoga have also been found to be useful in a few studies.
• Psychosocial interventions like cognitive behavioral therapy can be beneficial in patients with inadequate responses to initial treatments.
• Specialty consultations, which include consultations for rheumatologists, physiatrists, and psychiatrists, are recommended for patients not responding adequately to initial therapies. Treatment should be interprofessional and individualized, with close attention to the patient’s symptoms.
• There is limited evidence for analgesics, anti-inflammatory drugs, and complementary and alternative therapies like tai chi, yoga, and acupuncture.
• Some studies have shown benefits with neuromodulation techniques like transcranial stimulation, occipital and C2 nerve stimulation, and transcutaneous electrical nerve stimulation.

What else can Fibromyalgia be?

Fibromyalgia can often be confused with other conditions because it shares many common symptoms. These similar conditions can include:

• Polymyalgia Rheumatica (an inflammatory disorder)
• Spondyloarthritis (a type of arthritis that affects the spine)
• Inflammatory Myopathy (a condition that causes muscle inflammation)
• Systemic Inflammatory Arthropathies (a group of diseases that cause joint inflammation)
• Hypothyroidism (a condition where the thyroid gland doesn’t produce enough hormones)

By analyzing the patient’s medical history, conducting a physical examination, and using the few lab tests available, doctors can better distinguish fibromyalgia from these similar conditions.

What to expect with Fibromyalgia

Most long-term studies suggest that many patients continue to experience chronic pain and fatigue over time. However, these studies mostly focus on patients from specialized medical centers. In contrast, patients seen by local family doctors tend to have a better outlook.

Various factors, such as being female, having a lower income, being unemployed, being overweight, suffering from depression, and having a history of abuse, can negatively affect the outcome for patients with fibromyalgia.

Coping with fibromyalgia can be tough for many patients. Factors that could make things worse include having the disease for a long time, being very stressed, untreated depression or anxiety, avoiding work for a long period, depending on alcohol or drugs, and suffering from severe physical problems.

Possible Complications When Diagnosed with Fibromyalgia

Many people with fibromyalgia often struggle with a condition called fibro fog. This condition makes it hard for them to focus and can cause long-term memory problems. Additionally, people with fibromyalgia have a higher chance of needing to stay in a hospital for various reasons compared to those without this condition.

Common Experiences:

• Fibro fog leading to problems concentrating and remembering
• Higher chance of hospitalization

Preventing Fibromyalgia

It’s vital for people suffering from fibromyalgia to understand their condition before taking any prescribed medicine. Here are some important elements that patients should keep in mind:

Firstly, it’s important to understand that fibromyalgia is a real, recognized medical condition.

Secondly, stress and mood issues can play a part in fibromyalgia. So, learning how to relax and taking part in programs that help reduce stress can be beneficial. In fact, about 30% of people with fibromyalgia also experience severe depression at the time of their diagnosis, and throughout their lives, about 74% may encounter it. Similarly, around 60% may experience anxiety disorders in their lifetime. If you’re dealing with either of these conditions, seeking treatment is highly encouraged.

Lastly, maintaining good sleep habits is a crucial part of managing fibromyalgia, and taking care of any sleep issues that might be contributing to the symptoms of fibromyalgia is equally important. So, if you’re having trouble sleeping, seek advice and treatment.